4 Message from Direcr of Health Memo from Direcr of Health The Hawaii State Department of Health is pleased present Injuries in Hawaii: This report contains the latest findings on the leading causes of injury mortality and morbidity in Hawaii. Injuries are a major public health problem in Hawaii. They are by far the leading cause of death among children and young adults, and the fourth leading cause of death among state residents of all ages. Over the 5-year period covered in this report, a tal of 3,355 residents died from their injuries. The information in this report is for health and safety professionals, policy makers, and for everyone interested in protecting and improving the health of the people of Hawaii. The report includes descriptions of the geography and magnitude of the problem, trends, and populations at higher risk, and provides insight in some of the circumstances of these injury fatalities. It is crucial that good data be available guide prevention and policy efforts reduce injuries in Hawaii. This report is a first step. Please join the Department of Health, state and local agencies, and community organizations in working ward a safer Hawaii. Additional copies of this report and other injury prevention information may be obtained by calling the Department s Injury Prevention and Control Section at Loretta J. Fuddy, ACSW, MPH Direcr of Health Hawai i State Department of Health 1

5 Introduction What is the leading cause of death among Hawaii s children and young adults? The answer is not infectious disease or chronic diseases, such as cancer, but a public health problem that is chiefly non-medical in nature: injuries. The field of injury includes a diversity of events, ranging from unintentional mor vehicle crashes, drownings, falls, and poisonings, assaults and suicides. Injuries currently account for more deaths among Hawaii residents aged 1 39 years than all other diseases combined. Injuries are also a leading cause of mortality in later ages, and for some outcomes (e.g. suicides) the highest risks are seen in the elderly. There are risk facrs for injuries, just as there are for certain diseases. To a large degree, many injuries can be prevented by reducing these risk facrs, either prevent the original cause (e.g. observing posted speed limits prevent a crash) or the severity of the injury (e.g. utilizing seat belts). Injury risk facrs generally take two forms: risks imposed by the physical environment in which the injury takes place, and perhaps more commonly, individual behaviors which place a person at risk. This report describes fatal injuries in Hawaii over the period, with an emphasis on the environmental and individual risk facrs involved. This includes the geographic mapping of fatal injuries, and the analysis of the demography and behaviors of the victims. For many types of fatal injuries, this involved linking the basic information contained on death certificates more detailed information from crash reports, aupsy records, and criminal investigations. Nonfatal injuries over the period are also described in this report. These far outnumber fatal injuries and in many respects impose a greater public health burden. Although this report provides perhaps the most detailed summary of injuries currently available in the state, it was not intended be completely comprehensive. Readers who are interested in further information on a given area are encouraged contact the Injury Prevention and Control Section. This report is intended bring attention the problem of injuries, and help inform and direct efforts prevent fatal injuries in Hawaii. Introduction 2

6 Executive Summary Fatal injuries are a major public health problem in Hawaii, constituting the 4th leading cause of death among state residents. Injuries are by far the leading cause of mortality among residents aged 1 4 years, accounting for more deaths in this age group than all other diseases combined. This report describes the magnitude of fatal injuries in the state, examines trends over time, and identifies geographic areas and segments of the population that are at increased risk of fatal injuries. This detailed report is a first step in bringing attention the problem of fatal injuries, and providing information design and direct injury prevention programs. Executive Summary Although a leading cause of mortality, fatal injuries are relatively less common in Hawaii, compared the rest of the United States. The age-standardized 5-year rate for unintentional injuries was 17% lower in Hawaii, a statistically significant difference. The homicide rate in Hawaii was roughly one-third of that for the rest of the U.S., while the suicide rates were more comparable. A tal of 3,355 residents were killed by injuries over the 5-year period. Most deaths (2,159, or 64%) were unintentional, 795 (24%) were suicides, and 112 (3%) were homicides. The intent could not be determined for 283 (8%) deaths. There was no trend in the annual rate of all fatal injuries, but there was a significantly increasing trend in the suicide fatality rate. The rate of deaths from unintentional injuries decreased significantly over the period, but an increase in 211 resulted in no clear trend over the entire 5-year period. The rate of homicides decreased significantly if only the period was considered. Although of a lesser severity, nonfatal injuries greatly outnumber fatal injuries, and constitute significant medical and financial burdens for the residents of Hawaii. For every resident who dies from an injury there are nearly 1 others who are hospitalized for nonfatal injuries, and another 118 who are treated and released from emergency departments (EDs). These ratios translate 5,98 hospitalizations from nonfatal injuries and nearly 8, visits EDs each year in Hawaii. There was a significantly increasing trend in the annual number of nonfatal injuries treated at hospitals in Hawaii, from 85,675 in 27 87,111 in 211. Unintentional injuries, by main categories Mor vehicle crashes, occupants (excluding morcyclists) Fatal injuries This category was the 4th leading cause of fatal injuries Hawaii residents, averaging 58 deaths per year. About one-third (32%) of the victims were years of age. Most (73%) of the victims were males. Fatality rates were significantly higher among Neighbor Island residents, compared Oahu residents. The rates for residents of Hawaii and Kauai counties were particularly high, more than 4 times higher than that computed for Honolulu County. Trend: decreasing Total: 29, Ave: 58/year Age groups: 15-24y = 31% Gender: 73% M, 27% F County tals and 5-year rates (deaths/1,): y M F County Num. Rate Hawaii Honolulu Kauai Maui

7 More than half (57%) of the fatal crashes occurred during nighttime hours (7:29 p.m. 5:31 a.m.), and 61% involved only a single vehicle. Lack of restraint use was a major risk facr for occupant fatalities, as less than half of the victims (47%) were wearing seat belts at the time of the crash. Restraint use was especially low among back seat passengers (25%). Speeding was the most common contributing facr, noted for 41% of the drivers. Substance use was also an important contributing facr, as 4% of the drivers involved in fatal car crashes tested positive for alcohol, almost one-quarter (23%) tested positive for drugs, and nearly half (49%) tested positive for either alcohol or drugs. The peak age of alcohol use among drivers was years of age, as 56% tested positive for alcohol. More than half (56%) of the fatalities from car crashes were related alcohol consumption by at least one driver involved in the crash. Nonfatal injuries There were more than 4 nonfatal injuries among car occupants each year in Hawaii, with a decreasing annual trend. Most (91%) of the injuries were treated in EDs. Patient age was widely distributed, although 27% were years of age, and this age group also had by far the highest rate of injury. There were nearly equal numbers of female (52%) and male (48%) patients. Trend: decreasing Ave: 4618/year Treatment: 424 ED, 414 hosp. E D (91%) hos p. (9%) Age groups: 15-24y = 27% y County tals, annual number and rate (/1,): The nonfatal injury rate for residents of Hawaii County was significantly higher than the rate for residents of any other county, while the rate for Honolulu County residents was significantly lower than that for residents of any other county. Almost all (95%) of the injuries were coded as traffic, or occurring on public roads. Patients were hospitalized for an average of nearly 1 week, with nearly $46, in average medical charges per patient. EMS data and 27 linked data (EMS, DOT, HHIC, FARS, death certificates) Most (86%) of the injured occupants treated by EMS were wearing seatbelts. Restraint use was strongly associated with EMS patient disposition, including a 7-fold increase in mortality rate among unrestrained occupants (4.5%) compared those who wore seatbelts (.6%). Probable alcohol use was noted for about 1% of the patients, and drinkers were significantly less likely use seatbelts (71%, vs. 88% for other occupants). Linked data from 27 showed unrestrained EMS patients had more than twice (2.3) the odds of an injury that required hospitalization or resulted in death, compared restrained occupants, and more than triple (3.2) the odds of a fatal injury. These excess risks were statistically independent of patient age, gender, or the county of the crash County Num. Rate Hawaii Honolulu Kauai Maui Executive Summary Hawaii Trauma Registry (xicology data) About one-third of the injured resident occupants in the HTR tested positive for alcohol (32%) or illicit drugs (35%). Considered gether, more than half (52%, or 626) of the occupants tested positive for either alcohol or drugs. Occupants who were drinking were significantly younger than those who tested negative for alcohol (32 vs. 41 years, on average), more likely be male (75% vs. 56%), and less likely have used seat belts (46% vs. 63%). 4

8 Mor vehicle crashes, morcyclists Fatal injuries Deaths among morcyclists were the 6th leading cause of fatal unintentional injuries in the state, accounting for 146 tal deaths from Nearly half (45%) of the victims were adult males 2 4 years of age. Most (73%) of the decedents were riding morcycles; there were also 27 moped riders who were killed, including 16 over the period. The 5-year fatality rates were significantly higher for residents of Hawaii and Maui counties compared Honolulu County. Executive Summary Trend: no trend Total: 146, Ave: 29/year Age groups: 2-34y = 41% Gender: 94% M, 6% F M F County tals and 5-year rates (deaths/1,): Almost half (46%) of the fatal crashes did not involve another vehicle, although that proportion was lower (26%) among the fatally injured moped riders. Only about one-fourth (27%) of all riders were wearing a helmet at the time of the crash, including only 7% of the moped riders. Nearly half (47%) of the decedents tested positive for alcohol, and 29% for illicit drugs. Alcohol use was most common among drivers who crashed during nighttime (66%) and among those in crashes without another mor vehicle (69%). About half (51%) of the fatally injured drivers did not have a valid morcyclist license, and that proportion was significantly higher among those who had consumed alcohol (58%, vs. 44% among other drivers). More than one-halt (58%) of the riders were noted have been speeding at the time of the crash, a proportion that was higher among morcyclists (62%) and those who crashed on Oahu (66%). Nonfatal injuries There was an decreasing trend in the annual number of nonfatal injuries among morcyclists over the period, but an increase in 211. More than 1 were treated in EDs each year and another 276 were hospitalized. Patient age was narrowly distributed, with 51% between 15 and 34 years of age. The peak age for rates of both ED visits and hospitalizations was among 2 24 year-olds. Most (83%) of the patients were males. Trend: no trend Ave: 1287/year Treatment: 144 ED, 276 hosp. E D (79%) hos p. (21%) 45 y Age groups: 15-34y = 51% y County Num. Rate Hawaii Honolulu Kauai 7 - Maui County tals, annual number and rate (/1,): County Num. Rate Hawaii Honolulu Kauai Maui Although about half (54%) of the patients were residents of Honolulu County, residents there had significantly lower rates of nonfatal injuries than residents of any other county. Injury rates were approximately twice as high among residents of Neighbor Islands. Forty-four percent of the crashes did not involve a collision, but were due loss of control by the rider. Three-fourths (75%) of the nonfatal injuries were coded as traffic related, or occurring on a public roadway, while 25% were in non-traffic environments, including off-road crashes. Nearly one-fifth (19%) of the patients who were injured in non-traffic crashes were 5 14 years of age. The average hospitalization was nearly 1 week in duration

9 and resulted in over $51, in medical charges. About two-thirds (64%) of the hospitalized patients and one-quarter (23%) of those treated in EDs had fractures. EMS data and 27 linked data (EMS, DOT, HHIC, FARS, death certificates) About 55% of the EMS Patients were riding morcycles (55%), and 4% were riding mopeds (status unknown for 5%). About two-thirds (65%) of all riders were wearing a helmet. The proportion not wearing helmets was significantly higher, nearly doubled, among the moped riders (68%), compared morcycle riders (38%). Patient condition differed by helmet usage, as helmeted riders were significantly more likely be transported with minor or moderate injuries (23%, compared 19% for unhlemeted riders), and significantly less likely be transported in critical condition (1.9% vs. 3.7%). The mortality rate among helmeted riders (2.5%, or 31 of 1249) was also significantly less than that among unhelmeted riders (4.6%, or 86 of 1879). Probable alcohol use was noted for about 12% of the patients, and alcohol users were significantly less likely have worn helmets (14%, vs 41% among those with no alcohol use). Linked data from 27 showed the odds of sustaining an injury that required hospitalization or resulted in death were 4% higher among unhelmeted rides compared helmeted riders, and the former also had more than twice the odds (2.2) of a fatal injury. The protective effects of helmet use were magnified if only morcycle riders were considered. Unhelmeted morcycle riders had twice the odds of an injury that required hospitalization or resulted in death, more than 3 times the odds of a fatal injury, and 3 times the odds of a TBI. Hawaii Trauma Registry (xicology data) About one-fourth (26%) of the injured resident morcycle/moped riders in the HTR tested positive for alcohol, including 21% (178) with BAC levels of.8 or greater, and 14% (117) with BAC levels of.16% or greater. Moped riders were significantly more likely than morcyclists have been drinking (31% vs 24%, respectively). More than half (54%, or 464) of the riders tested positive for either alcohol or drugs, including most (78%) of the 285 moped riders. Alcohol usage was 4 times more common among those who crashed during night time (54%) compared those who crashed between 6:3 a.m. and 7:29 p.m. (14%). Mor vehicle crashes, pedestrians Fatal injuries There was no statistically significant trend in the annual number of pedestrian fatalities, although the highest tal occurred in 27 (37 deaths). Senior-aged residents comprised 47% of the victims, and the fatality rates increased dramatically across the oldest age groups. Most (69%) of the victims were hit on Oahu, but there were no significant differences in county-specific fatality rates. Almost all (8%) of the victims who were 65 years or older were hit on Oahu, and the fatality rate for Oahu seniors was statistically comparable that for seniors living on Neighbor Islands (36 vs. 22 deaths /1,, respectively). Trend: no trend Total: 13, Ave: 26/ year Age groups: 65 y and older = 47% y Gender: 58% M, 42% F M F County tals and 5-year rates (deaths/1,): County Num. Rate Hawaii Honolulu Kauai 4 - Maui Executive Summary There were 2 peak times for pedestrian fatalities: 27 crashes (21% of the tal) occurred between 5:31 a.m. and 9:29 a.m., and 4 (31%) ok place between 5:31 p.m. and 11:29 p.m. Only 34% of the victims were in a crosswalk at the time of the crash; a nearly equal proportion (35%) were hit on open stretches of roadway. The most common speed 6

10 Executive Summary zone was 25 miles per hour (45% of crashes). Almost two-thirds than half (63%) of the senior-aged victims were hit in 25 mph or slower zones, compared 33% of pedestrians under the age of 65 years. According FARS data from 27 21, more than one-quarter (26%) of the 84 fatally injured pedestrians tested positive for alcohol, and 25% had BAC levels of.8% or higher. Alcohol use was significantly higher among male victims (42%) compared females (6%). The highest prevalence of alcohol use was seen among victims in the year age group (7%, or 7 of 1), and the year age group (52%, or 11 of 21). According FARS data, 39% (33) of the pedestrian victims were in the roadway erroneously, most commonly by improper crossing of roadway or intersection, including jaywalking (21%, or 18 victims). Including the victims who tested positive for alcohol or drugs, 54% (or 45) of the pedestrians made an error that contributed the crash. More than half (59%, or 52) of the 88 drivers made an error which contributed the crash. Most commonly, they were described as inattentive (38%), failed yield the right of way (25%), or were speeding (18%). Nonfatal injuries The annual number of nonfatal injuries pedestrians generally decreased from 649 in in 211. About one-quarter (23%) of the patients with nonfatal injuries were admitted hospitals, the highest such proportion for any unintentional injury category. Patient age was widely distributed, but one-third (33%) were in the 5 24 year age group. This group also had the highest rate of nonfatal injuries that were treated in EDs, while senior aged residents had the highest rates of hospitalizations Trend: decreasing Ave: 61/year Treatment: 464 ED, 137 hosp. E D (77%) hos p. (23%) Age groups: 5-24y = 33% y County tals, annual number and rate (/1,): County Num. Rate Hawaii Honolulu Kauai Maui The rates of both ED visits and all injuries (ED visits combined with hospitalizations) were lowest for Maui County residents, although all county-specific rates were statistically comparable. Most (88%) of the nonfatal injuries were coded as traffic related, or occurring on a public roadway, while 12% were in non-traffic environments, including private roads, driveways and parking lots. Thirty percent of the patients injured in non-traffic crashes were in the 1 14 year age group. Patients were hospitalized for an average of 9 days, with nearly $6, in medical charges. Hospitalizations accounted for most (73%) of tal patient days and 87% of the $9.4 million in tal medical charges. EMS data and 27 linked data (EMS, DOT, HHIC, FARS, death certificates) There were 2 peak periods for the time of the EMS-attended crashes, from 6:31 a.m. 8:29 a.m. (13%, or 287 crashes), and from 2:29 p.m. 7:29 p.m. (35%, or 788 crashes). The time distribution differed by patient age, as crashes with senior-aged pedestrians were more likely occur during daytime hours (86%), compared crashes involving pedestrians under 65 years of age (73%). Patient condition differed by age, as senior-aged pedestrians were significantly more likely be transported a hospital, compared pedestrians under 65 years of age (85% vs. 79%, respectively), and had a significantly higher mortality rate (1.3%, or 47 of 456, vs. 3.6%, or 67 of 1855). The mortality rate was also significantly elevated among pedestrians who were hit during night time hours (7.4%, or 42 of 566), compared those hit between 5:31 a.m. and 7:29 p.m. (4.1%, or 72 of 1747), despite the younger age distribution among the former. Probable alcohol use was noted for about 9% of the patients. Patients who had used alcohol had generally worse dispositions, and were more than three times as likely require transport in critical condition, and nearly twice as likely have died, compared those who did not use alcohol. 7

11 Hawaii Trauma Registry (xicology data) Only 16% of the injured pedestrians in the HTR had been drinking at the time they were hit. This percentage was significantly higher among those under 65 years of age (22%), as only 2% (3) of the 138 senior-aged pedestrians tested positive for alcohol. Illicit drug usage was documented for 25% of the patients, including 3% of those who were under 65 years of age. Alcohol use was nearly 8 times likely among pedestrians hit during night time hours (41%) than among those hit between 6:3 a.m. and 7:29 p.m. (5%). Mor vehicle crashes, bicyclists Fatal injuries There were between 2 and 4 bicyclists killed in Hawaii each year, and 8% (12) of the 15 deaths occurred on Oahu. There was no apparent high-risk age group. Almost all (87%, or 13) of the bicyclists killed over the 5-year period were males. Most (87%, or 13) of the victims were hit by a car; 2 others died after falling off their bicycles. Only 2 of the victims were wearing helmets at the time of the crash (status unknown for 2 others). There was no notable peak time of the day for the crashes; most (64%, or 9) occurred between during daylight hours between 7:31 a.m. and 7: p.m. Trend: no trend Total: 15, Ave: 3/year Age groups: widely distributed y Gender: 87% M, 13% F M F County tals and 5-year rates (deaths/1,): County Num. Rate Hawaii - Honolulu Kauai - Maui 3 - Almost all (91%, or 1) of the 11 traffic-related crashes (from 27 21) involved cars traveling straight on the road; only 1 crash was due a car making a turn. Two (18%) of the 11 bicyclists tested positive for alcohol, and 4 (36%) tested positive for drugs. Overall, about half (54%, or 6) of the victims tested positive for either alcohol or drugs. Besides substance use 2 bicyclists were traveling against traffic at the time of the crash and another failed yield the right-of-way. Four (36%) of the 11 drivers made an error which contributed the crash, most commonly substance use and speeding (2 instances each). Nonfatal injuries There were more than 12 nonfatal injuries bicyclists each year, with a generally increasing trend. Most (92%) of the injuries were treated in EDs. Males comprised 75% of the patients, including 8% of those who were hospitalized. Nearly one-third (31%) of the patients were 5 14 years of age, and the injury rate for 5 14 year-olds (244 injuries/1, residents) were more than 3 times higher than the rate for residents of other ages (74/1,). Executive Summary 8

12 Executive Summary Trend: increasing trendave: 1237/year Treatment: 1133 ED, 15 hosp. E D (92%) hos p. (8%) 4 2 Age groups: 1-14y = 38% County tals, annual number and rate (/1,): County Num. Rate The injury rate for Kauai County residents was significantly higher than the rates for any other county, and approximately double the rate estimates for residents of Honolulu or Maui counties. Almost all (85%) of the injuries were coded as non-traffic, or occurring on private roads, driveways, or off-road environments. Most of the injuries treated in EDs (88%) and requiring hospitalization (71%) were coded indicate crashes that did not involve a collision with another vehicle or object, but were probably due the patient falling off of the bicycle. Although 92% of the patients were treated in EDs, hospitalizations comprised 32% of the treatment days and 66% of the tal medical charges of $5.8 million/year. Most (63%) of the hospitalized patients had fractures, including 15% with skull fractures and 2% with leg fractures. More than one-third (38%) of these patients had a traumatic brain injury. EMS data and 27 linked data (EMS, DOT, HHIC, FARS, death certificates) Most (73%) of the EMS-attended bicyclist crashes were distributed over the 11-hour period of 7:31 a.m. 6:29 p.m., with a peak from 4:31 p.m. 6:29 p.m. (17%). About half (53%) of the injuries involved mor vehicles and 47% did not. Only 27% of the injured bicyclists wore helmets. Unhelmeted riders had a significantly higher proportion of critical or fatal injuries (2.1%, or 22 of 131), compared helmeted riders (.7%, or 3 of 458). These differences were accentuated among crashes that involved mor vehicles, as the proportion of unhelmeted bicyclists with critical or fatal injuries was 3.1% (17 of 54), compared.9% (2 of 214) among helmeted riders. Probable alcohol use was noted for about 9% of the patients. If only the bicyclists with known alcohol and helmet status were considered, helmet use was 5 times higher among those who did not consume alcohol (35%), compared the drinkers (5%). Linked data from 27 showed odds of sustaining an injury that required hospitalization or resulted in death were 8% higher among unhelmeted rides compared helmeted riders, although this estimate was only of borderline statistical significance (p=.11). Hawaii Trauma Registry (xicology data) Only 11% of the injured bicyclists in the HTR had been drinking at the time they were injured. This percentage was nearly three times higher among those hurt in crashes that did not involve a mor vehicle compared those who were hit by mor vehicles (15% vs. 6%, respectively). About one-quarter of the bicyclists tested positive for illicit drugs, most commonly narcotics (17%), and this proportion did not differ by the type of crash. Overall, one-third (33%, or 89) of the 271 patients tested positive for either alcohol or drugs. None of the 28 bicyclists who had been drinking were wearing a helmet at the time of the crash, compared 27% usage among those who tested negative for alcohol, and 31% among those who were not tested y Hawaii Honolulu Kauai Maui Drownings (residents and non-residents) Fatal injuries There was no clear trend in the annual number of drownings, although the 79 deaths in 211 was the highest tal since at least Most of the high tal in 211 was due drownings on Honolulu and Maui counties. About half (53%) of the victims were Hawaii residents, 36% from the U.S. mainland, and 12% from foreign countries. The ages of 9

13 the victims were widely distributed, although only 8% were under 18 years of age. Almost all (83%) were males. About half (47%) of all the victims drowned on Oahu. If only drownings among Hawaii residents were considered, Oahu residents had the lowest rates, significantly lower than rates for Neighbor Island residents as a whole. If non-residents are also included, the highest (unadjusted) rate was computed for Kauai, approximately twice as high as rates for Hawaii County and more than 3 times the rates for Honolulu County. Trend: no trend Total: 332, Ave: 66/year Age groups: 45-64y = 42% Gender: 83% M, 17% F M F Hawaii residents only: County tals and 5-year rates (deaths/1,): Most (78%, or 259) of the victims drowned in the ocean or saltwater environments, almost all of whom (96%) were 18 years or older. Unintentional immersions led 13% of these drownings, including 31 victims who fell in or were swept in the ocean. Other common activities were swimming (29% of victims), snorkeling (22%), and free diving (9%). According aupsy records, intrinsic or personal facrs contributed over half (61%) of the saltwater drownings in Honolulu County from The most common intrinsic facr was circulary diseases, present among 46% of the victims of all ages, and 69% of those aged 5 years and older. Only 13% of the victims tested positive for alcohol, and only 7% had BAC levels of.8% or greater. Illicit drug use was considered a contribution 12% of the drownings. Apart from ocean drownings, there were 36 drownings in swimming pools, 21 in rivers and streams, and 12 in bathtubs. Only 3 (8%) of the 36 victims who drowned in swimming pools were under 5 years of age, as victim age was widely distributed in this environment Nonfatal injuries (near drownings) There was no clear trend in the annual number of near drownings, which averaged 235 per year. Hawaii residents comprised a slight majority (55%) of all patients treated for near drownings, but only 41% of those who were hospitalized. ED patients were significantly younger on average than those who were hospitalized (31 vs. 4 years of age), with more than half (56%) in the year age group. Among Hawaii residents, county-specific rate estimates were generally comparable except for Hawaii and Maui county residents Trend: no trend Ave: 235/year Treatment: 163 ED, 73 hosp. ED (69%) hosp. (31%) Age groups: 1-24y = 39% y y County Num. Rate Hawaii Honolulu Kauai Maui Hawaii residents only: County tals, annual number and rate (/1,): County Num. Rate Hawaii Honolulu Kauai Maui 9 6. Executive Summary Hospitalizations were of a relatively short number of days (4.1, on average), but because each hospitalization incurred over $28, in charges, they comprised most (91%) of the tal $2.3 million in annual medical charges in the state. Swimming (4%) and surfing, windsurfing and boogie boarding (32%) were the most common activities for the patients overall, although swimming was a more likely cause among non-residents (45%), while the latter activities were more common among residents (39%). 1

14 EMS data Almost all (94%) of the incidents EMS responded occurred during day time hours, including 8% between 9:31 a.m. and 5:29 p.m. More than half (59%) of the patients were Hawaii residents. About 43% of the near drownings occurred in bodies of water, which could include both freshwater and saltwater environments. About one-third (3%) were in patient residences (1%), public buildings (12%), hotels (5%), and health care facilities (3%). Most (77%) of the patients were either transported in serious (46%) or critical (32%) condition, with no significant differences in the distribution of patient condition between residents and non-residents. Probable alcohol use was noted for only 4% of the patients. Near drownings that occurred during night time hours were significantly more likely involve alcohol consumption than day time incidents, however (21% vs. 3%). Executive Summary Hawaii Trauma Registry (xicology data) Only 8% of the adult-aged (18 years and older) HTR near drowning patients were positive for alcohol, and only 9% tested positive for illicit drugs, although there was no xicological testing for about two-thirds of the patients. Substance use was somewhat higher among resident patients, although this comparison is limited by the small sample sizes and the lack of testing. Falls Fatal injuries Falls were the most common type of fatal unintentional injury in the state, with the 541 deaths accounting for 25% of the tal. More than three-quarters (79%) of the victims were aged 65 years or older, and the risk of fatal falls increased dramatically across the senior age range. Males comprised the majority (78%) of victims under 65 years of age, while gender was more equally distributed for the senior-aged victims. Honolulu County residents comprised most of the victims of all ages (77%) and those who were 65 years or older (81%). The fall fatality rate estimate for senioraged residents of Honolulu County was significantly higher than the rates for residents of Kauai or Maui counties, and 45% higher than for Neighbor Island residents considered as a whole. Trend: no trend Total: 541, Ave: 18/ year Age groups: 65y or older= 79% y Gender: 57% M, 43% F M F County tals and 5-year rates (deaths/1,): County Num. Rate Hawaii Honolulu Kauai Maui Death certificates provided little information on the causes of falls, as most were coded as falls on the same level with no further description (48%), or unspecified causes (32%). Falls from stairs or steps were the most specifically coded cause, but comprised only 4% of the tal. More than half (61%) of the falls occurred at the residence of the victim, including 68% of the senior-aged victims. Nonfatal injuries Falls were the leading cause of nonfatal injuries among Hawaii residents, with nearly 21, ED visits and over 2,7 hospitalizations each year. The annual number of injuries generally increased. Children aged 1 14 years comprised 27% of all patients, but about two-thirds (68%) of those who were hospitalized were 65 years or older. Gender was equally distributed among patients treated in EDs, but females comprised 59% of the patients that were hospitalized. 11

15 Trend: increasing trend Ave: 23,625/year Treatment: 2,92 ED, 2,75 hosp. E D (89%) hos p. (11%) Age groups: 1-14y = 27% y County tals, annual number and rate (/1,): Residents of Hawaii and Kauai counties had significantly higher rates of nonfatal injuries from falls than residents of Honolulu and Maui counties. The residents of Honolulu County had the lowest rates of hospitalizations. Among the more specifically coded injuries, the most common causes were falls from stairs, steps and escalars (5.3% of the tal), beds (3.7%), skateboards (3.5%), and chairs, playground equipment, and ladders (about 2% for each). At least half (53%) of the falls that caused hospitalizations in seniors occurred in home environments. This proportion increases 84% if only records with specific information on location are considered. The most common activity related the falls was walking, marching and hiking, accounting for 3% of the tal. Skateboarding, running, tackle football, and bathing and showering were also prominent activities. Hospitalizations averaged nearly 1 week in duration, resulted in over $31, in medical charges, and accounted for 72% ($84 million) of the tal annual charges of $116.6 million. Fractures were present in nearly three-fourths (74%) of the hospitalized patients, including 29% with hip fractures. Additional data is presented for nonfatal falls specifically among senior-aged residents. EMS data More than half (57%) of the EMS-attended falls occurred in the home or residence of the patient, and this proportion was significantly higher among the seniors (71%) compared younger aged patients (41%). More than half (54%) of the patients were 65 years or older, including 22% who were 85 years or older. Senior-aged patients had worse dispositions, as they were more likely be transported in serious condition (49%, compared 4% of younger age patients) and less likely be released at the scene (12% vs 19%, respectively). Probable alcohol use was noted 8% of the patients, and male patients were more than twice as likely have used alcohol compared females (12% vs. 5%). Hawaii Trauma Registry (xicology data) Only 11% of the adult-aged (18 years and older) HTR resident patients who were injured by falls were positive for alcohol, with 4 times higher use among patients in the year age group (19%), compared senior-aged patients (5%). Fifteen percent of the patients tested positive for illicit drugs, most commonly narcotics (11%). Considered gether, about one-quarter (24%, or 587) of the patients tested positive for either alcohol or drugs, although that proportion was much lower among the senior-aged patients (13%), compared younger patients (36%) County Num. Rate Hawaii Honolulu Kauai Maui Executive Summary Poisonings Fatal injuries There was an increasing trend in the annual number of unintentional poisonings. (There was no consistent trend in the number of poisonings of undetermined intent over this period.) Victim age was narrowly distributed, as 58% were in the year age range. Males comprised 78% of the victims. Most (82%) of the victims were poisoned on Oahu, and the highest fatality rates were computed for Honolulu County residents. Inclusion of poisonings of undetermined intent resulted in significantly lower rates among Oahu residents compared Hawaii or Maui county residents, so these comparisons are unreliable. Drugs caused almost all (93%) of the poisonings, including 32% from narcotics and hallucinogens and 34% from sedative-hypnotic and psychotropic drugs. 12

16 Trend: increasing trend Total: 49, Ave: 98/year Age groups: 45 64= 58% Gender: 78% M, 22% F County tals and 5-year rates (deaths/1,): Executive Summary Nonfatal injuries There was an increasing trend in the number of nonfatal poisonings, but this was evident only for ED visits among Honolulu and Maui county residents. Gender was nearly equally distributed with 53% male patients. Patient age was broadly distributed, although one-quarter (26%) were 1 14 years of age. Seniors comprised only 13% of all patients, but (23%) of those who were hospitalized. Rates of ED visits were highest by far for residents under 5 years of age, nearly 5 times higher than the rate for all other age groups. Residents of Honolulu and Maui counties had comparable injury rates, significantly lower than the rates for residents of Hawaii and Kauai counties. Trend: increasing trend Ave: 111/year y Treatment: 85 ED, 27 hosp. E D (8%) hos p. (2%) Age groups: 1-14y = 26% M F County tals, annual number and rate (/1,): Patients were hospitalized for slightly over 3 days on average, with nearly $18, in medical charges. Most (76%) of the poisonings were caused by drugs or medicinal substances, including 92% of those that required hospitalization. Narcotics caused 21% of the hospitalizations, tranquilizers 13%, aromatic analgesics (which include acetaminophen, or Tylenol) 8%, and cardiovascular agents 8% y County Num. Rate Hawaii Honolulu Kauai Maui County Num. Rate Hawaii Honolulu Kauai Maui Suffocations Fatal injuries The annual number of suffocations varied inconsistently between 24 and 37 deaths. The age distribution was bimodal, as most (68%) victims were 75 years or older, but there were also 24 victims (16%) who were under 4 years of age. Twenty-two of the victims were infants, all but 3 of whom suffocated in their beds or sleeping environments. Most (89%) of the victims suffocated on Oahu, including 92% of those who were 65 years and older. The most commonly specified causes were inhalation of food (19% of suffocations) or gastric contents (2%). Most (58%) were coded as inhalation of other objects with little further detail available. Including deaths from SIDS and unspecified causes of mortality as well as infant suffocations, there was an average of 15 infant deaths a year that were sleep-related or possibly sleep-related, with no trend in the annual number. 13

17 4 3 2 Trend: no trend Total: 149, Ave: 3/year Age groups: 65y or older= 68% *Includes only residents aged 65 years and older. Gender: 67% M, 33% F M F County tals and 5-year rates* (deaths/1,): Nonfatal injuries There was a decreasing trend in the overall number of nonfatal suffocations in the state, due mostly decreases in ED visits over the period. More than half (53%) of the patients were under 5 years of age. Senior-aged residents comprised 58% of the patients who were hospitalized. Males comprised a slight majority (53%) of the patients. Oahu residents comprised 59% of the patients, but rates of ED visits for nonfatal suffocations were significantly higher among residents of Neighbor Islands (14 visits per year/1, residents) compared Oahu residents (9 visits/1,) Trend: decreasing trend Ave: 154/year y Treatment: 152 ED, 16 hosp. ED (91%) hosp. (9%) Age groups: -14y = 62% County Num. Rate Hawaii 1 - Honolulu Kauai 2 - Maui 5 - County tals, annual number and rate (/1,): County Num. Rate Honolulu Kauai 1 - Maui More than half (61%) of the hospitalizations were caused by the inhalation of food and somewhat less commonly (33%) by the inhalation of other (non-food) objects. Non-food objects caused 61% of the ED visits for nonfatal suffocations, while inhalation of foods caused 38%. Almost all (97%) the suffocations were diagnosed as foreign body entering through orifice y Executive Summary Intentional injuries Suicides and suicide attempts Fatal injuries There was a generally increasing trend in the number of suicides in the state, and the 195 deaths in 21 was by far the highest tal in the 21-year period ( ) for which data was available. Victim age was widely distributed, although almost all (95%) were 19 years or older. The highest fatality rates were computed for residents aged years and those 85 years and older. Male victims outnumbered females by approximately More than half (58%) of the victims were residents of Oahu, but the fatality rate for Oahu (58/1, residents) was significantly lower than the rate for the combined Neighbor Islands (94/1,). 14

18 Executive Summary Trend: increasing Total: 795, Ave: 159/year Age groups: 2 6y= 74% Gender: 76% M, 24% F M F County tals and 5-year rates (deaths/1,): The most common mechanism was by hanging or suffocation (49% of the suicides), followed by firearm use (2%). Most (65%) of the Oahu victims had a documented hisry of mental illness (as variously defined), according aupsy records from The most common negative life events for the victims were related intimate relationship problems (34%), usually a break-up or divorce (12%), or serious illness or medical issues (26%). The latter was documented for 6% of the senior-aged victims. Over one-third (37%) had a hisry of substance abuse, 19% had a BAC level over.8%, and 34% tested positive for illicit drugs. Nearly one-third (32%) of the victims had a previous suicide attempt documented in the record, and more than half (56%) had verbally threatened suicide. Nonfatal injuries There was an increasing trend in the number of nonfatal suicide attempts, which was only evident in the annual number of injuries that were treated in EDs. Slightly more than half (56%) of the injuries were treated in EDs, unlike most types of injuries. Most (58%) of the patients were under 35 years of age, and residents aged years had the highest rates of hospitalizations and especially ED visits. The gender distribution of patients was similar for both settings, with females comprising 57% of the tal. Trend: increasing trend Ave: 826/year y Treatment: 465 ED, 361 hosp. ED (56%) hosp. (44%) Age groups: 15-24y = 33% y County Num. Rate Hawaii Honolulu Kauai Maui County tals, annual number and rate (/1,): County Num. Rate Hawaii Honolulu Kauai Maui Residents of Kauai and Hawaii counties had significantly higher rates of nonfatal self-inflicted injuries compared residents of Honolulu and Maui counties. Over half (58%) of the ED visits and most (85%) of the hospitalizations were caused by poisonings from drugs or medicinal substances, most commonly from the analgesics, antipyretics, and antirheumatics class (22% of ED visits, 33% of hospitalizations), which includes both narcotics (heroin, and other opiates), as well as aspirin and acetaminophen. Female patients were more likely attempt by drug or medicinal poisonings (76%, vs. 62% for male patients). 15

19 Homicides and assaults Fatal injuries There were 112 victims of homicide over the 5-year period, with a significantly decreasing trend from 29 in in 211. More than half (58%) of the victims were in the year age range, but there were also 6 victims (5%) who were under 5 years of age. Males comprised 59% of the victims. The fatality rate for residents of Oahu (8.8 deaths/1, residents) was statistically comparable the rate for all Neighbor Island residents (8.4/1,). Trend: decreasing trend Total: 112, Ave: 22/year Age groups: 25 54y= 58% Gender: 59% M, 41% F M F County tals and 5-year rates (deaths/1,): The most common method was the use of firearms (35%), followed by stabbings (28%), and physical force or unarmed beatings (25%). According Uniform Crime Reports from 27 29, most (73%) of the homicide victims knew their assailant, and only a minority (19%) were killed by strangers. Female victims were most likely be killed by their intimate partner (37%, vs. 5% of male victims), while males were most likely be killed by extra-familial acquaintances (4%) or strangers (25%). Nonfatal injuries There were over 42 nonfatal injuries from assaults among Hawaii residents each year, with no clear trend over time. Males comprised two-thirds (67%) of the patients treated in EDs and an even greater proportion (89%) of those who were hospitalized. More than half (58%) of the patients were years of age; few (5%) were under 15 years of age, or over 65 years of age (1%). The peak age for rates of both ED visits and hospitalizations was the year age group, particularly 2 24 year-olds. Trend: no trend Ave: 4243/year y Treatment: 3936 ED, 37 hosp. ED (93%) hosp. (7%) Age groups: 15-24y = 33% y County Num. Rate Hawaii 17 - Honolulu Kauai 7 - Maui 7 - County tals, annual number and rate (/1,): County Num. Rate Hawaii Honolulu Kauai Maui Executive Summary The injury rate for residents of Hawaii County was significantly higher than for any other county, while the rate for residents of Honolulu County was significantly lower than any other county. Patients were hospitalized for nearly 5 days on average, with over $31, in charges for each admission. Unarmed beatings caused 7% of all injuries, and 61% of those that required hospitalization. Fractures were the most common type of injury (53%) that required hospitalization, including 44% of patients admitted with a skull fracture. 16

20 EMS data The number of EMS-attended incidents generally increased over the course of the day (starting at 6 a.m.), reaching a broad peak during the 7:31 p.m. 2:29 a.m. period (48% of the tal). The home or residence of the patient was the most common location for the assault (4%), followed by other indoor location or buildings (17%), most commonly public buildings (7%), and bars and restaurants (6%). One-fifth (2%) of the patients were transported in serious or critical condition. That proportion was highest among the senior-aged victims (29%). Probable alcohol use was noted for 29% of the patients. Patients who had consumed alcohol were significantly less likely be released at the scene (34%, vs. 52% for other patients), and twice as likely be transported in serious condition (31% vs. 15%, respectively). Executive Summary Hawaii Trauma Registry (xicology data) Nearly half (46%) of the adult-aged (18 years and older) HTR resident patients who were injured by assaults were positive for alcohol, and more than one-third (38%) tested positive for illicit drugs. About three-fourths (76%, or 286) of the 375 drinkers had BAC levels of.8% or greater. THC was the most commonly documented drug (19% of the patients), followed by amphetamines (15%) and narcotics (15%). Considered gether, about two-thirds (67%) of the patients tested positive for either alcohol or drugs. Alcohol use was significantly more likely among the male patients (49%) compared females (27%), among those injured on weekends (54% vs. 41% for those assaulted on weekdays), and among those assaulted during night time hours (54%, vs. 3% for those injured between 6:31 a.m. and 7:29 p.m.). 17

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